Introduction:
The introduction of steroids was both a boon and a bane. While it helped fight many disorders, the overuse of the medication caused an array of unwanted side effects. Steroid rosacea is one such complication of the excessive and unmonitored use of topical steroids. Fluorinated steroids, if applied continuously on the face, can cause a skin condition indistinguishable from rosacea called steroid-induced rosacea or ‘iatrosacea.’ It is characterized by centrofacial, periocular (around the eyes), and perioral (around the mouth) papules and pustules. If it is left unchecked, it can cause skin atrophy (wasting) and telangiectasia (widening of blood vessels).
What Is Steroid Rosacea?
Topical corticosteroid-induced rosacea-like dermatitis, or TCIRD, is a disease that occurs due to the prolonged and improper use of topical corticosteroids, or it can be a result of a rebound phenomenon that occurs when the use of topical corticosteroids is discontinued.
It typically occurs in the middle of the face. It is believed to be a variant of perioral or periorificial dermatitis. It should not be mistaken for steroid acne, which is caused by oral corticosteroids.
The main clinical manifestations include papules, pustules with a reddened area, and swollen skin. It is not a variant of rosacea, as there is a separate cause and progression. It is also known as:
-
Perioral dermatitis.
-
Light-sensitive seborrheid.
-
Steroid-induced rosacea.
-
Rosacea-like dermatitis.
-
Steroid dermatitis resembling rosacea.
What Are the Clinical Features of Steroid Rosacea?
Steroid rosacea is seen more commonly in adult women than in men, although it can affect children and men. The application of topical steroids for several weeks can result in redness in areas such as the eyelids, mid-forehead, cheeks, or chin. Clinically they appear as follows:
-
Small papules (bumps) or pustules. (pustules are pus-filled bumps).
-
The area may become itchy, scaly, or hot.
-
Telangiectasia can develop. It is the widening or enlargement of blood vessels, which are usually harmless but can be a symptom of other diseases.
-
Skin becomes highly sensitive.
-
The condition can flare up or worsen when the offending topical steroid is discontinued. This phenomenon is called rebound flare.
-
The primary lesions or eruptions are small discolorations on the skin (papules) or vesicles. When these bumps clear off, the area becomes red. If the topical steroid is still continued, the reddened area becomes inflamed and swollen (edematous). In some cases, the vesicles can be pustules or even nodules along with telangiectasia.
What Causes Steroid Rosacea?
As the name suggests, steroid rosacea is caused by topical corticosteroids. It is not entirely understood why steroids cause this condition. A few proposed theories include:
-
The proliferation of microorganisms in the skin.
-
The proliferation of organisms such as Demodex or hair follicle mites.
-
Immune response to cytokine release.
-
Formation of new blood vessels or rebound vasodilation.
-
Steroid rosacea is less likely to occur when mild steroids are used; the incidence increases with the usage of strong steroids.
-
It is also less prevalent when steroids are applied less frequently.
-
Steroids inhibit the natural vasodilators. This can lead to vasoconstriction and the build-up of many metabolites, such as nitric oxide. Once the steroid is discontinued, the vasoconstrictive effect is ceased, and the blood vessels dilate more than the original diameter because of the accumulation of nitric oxide. This leads to erythema (redness), pruritus, and a burning sensation of the steroid rosacea.
How Does the Disease Progress?
Steroids were introduced in 1951. At first, it was revolutionary. But with the introduction of new medicine came a new dermal condition. It has been given different names throughout the years, the latest being TCIRD (topical corticosteroid-induced rosacea-like dermatitis) since it describes the cause and appearance of the lesion.
A patient who has been prescribed a topical steroid for a certain condition responds well to the medication initially. But on continued and improper use of the topical steroid, they begin to develop rashes, which recur even when the drug is stopped. This condition of the development of rashes even when the medicine is discontinued is called the rebound phenomenon. The patients consult experts when the initial treating effect of the steroid is no longer found.
This condition often occurs when the patient seeks methods for flawless skin. Often the unmonitored use of over-the-counter products or self-treating of certain disorders causes this problem. Betamethasone valerate is the most common culprit in many of these cases, owing to the easy access and cost-effectiveness of the steroid.
What Are the Other Complications of Topical Steroids on Facial Skin?
-
In addition to steroid rosacea, topical steroid application on the face can have other adverse effects. Periorificial dermatitis is a less severe form of steroid-induced rash, which is characterized by small bumps around the lips, nose, and eyelids.
-
Steroid rosacea can also be confused with tinea faciei and tinea incognito.
-
Certain fungal infections can be masked by the use of topical steroids.
How to Manage Steroid Rosacea?
-
Steroid rosacea mostly responds well to treatment. Associated telangiectasia may persist for some more time.
-
Management of the condition can be challenging in some cases as the skin barrier on the face may be compromised and intolerant to topical therapy. Discontinuation of the steroid is the ultimate solution, but it is not easy, as flare-ups can occur. In mild cases, tapering of the steroid or replacement with a less potent steroid is suggested along with the use of emollients and followed by the complete stoppage of the steroid. In severe cases, oral antibiotics may be necessary for the treatment plan.
The Management Includes:
-
Discontinuation of the topical steroids. The medication is withdrawn slowly to prevent or minimize flare-ups. The withdrawal is made by reducing the frequency of use of the steroid or replacing it with a less potent steroid.
-
Non-oily moisturizers are to be used.
-
Oral tetracyclines such as Doxycycline are prescribed. After the discontinuation of the steroid, drugs like Tetracycline, macrolides or non-steroidal topical formulations are used. The complete clearing of the lesions can take up to several months after the treatment has started.
-
Short-term use of topical Pimecrolimus cream is found helpful.
-
The persisting telangiectasia can be treated with laser therapy.
Conclusion:
Steroid rosacea or topical corticosteroid-induced rosacea-like dermatitis (TCIRD) is a skin condition that occurs due to the excessive and prolonged use of topical steroids. This condition is characterized by bumps, pustules, or vesicles on the mid-face, mid-forehead, chin, or cheeks. The discontinuation of the steroid can also cause flare-ups. The management of the condition requires slowly tapering the steroid and eventually ceasing the administration; in severe cases, oral antibiotics may be necessary.
